Pulse

September 11, 2013

This evening, I listened with my stethoscope for the first time.

I have been waiting for the perfect moment ever since I received it a few weeks ago, and I felt that this evening was finally the time.  I had my first patient encounter today for my baseline assessment, which gave me the opportunity to meet with a standardized patient (a person portraying an actual patient).  It was both an eye-opening and humbling experience, and it drove home just how much I have to learn.  Thankfully, that is what medical school is about—the continual process of learning and doing our best to make each day a little better than the one before. 

I felt that it was symbolic for me to use my stethoscope for the first time on the day I met my first patient.  I have taken anatomy for nearly three weeks, have made it through my first quiz in Molecular Foundations of Medicine and can now name most of the coronary arteries, but today brought into sharp focus the fact that I am a physician-in-training.

Since today was a baseline experience, I had really no idea what to do once I entered the simulated exam room.  I did know that I needed to wash my hands with the sanitizing foam.  (Thanks to the generosity of the automatic foam dispenser, I was faced with the conundrum of drying my hands while trying to introduce myself.  Somehow, wiping my hands on my white coat didn’t seem suitable, so I settled for vigorously rubbing them together.)  I also remembered to introduce myself with my full name and indicate that I am a first-year medical student, but as I sat down, I realized how much I didn’t know.  What questions do you ask?  How do you follow up those questions?   

What do you do when you end up completely tongue-tied?

Yes, that happened to me.  My mind went blank about half a minute into the conversation, and I couldn’t think of what to say next.  Bewildered, I picked myself up after a few moments and kept going, realizing just how far I had to go.

So much to learn…

Today’s baseline encounter has been a very valuable experience, and one that will frame my studies in the coming months.  I know that with time and practice, I will gain the knowledge I need to ask the right questions, but I’m also thankful for this experience because it helped me to see what patient interactions can look like when I don’t come in with much of an agenda.  I hope to gain the structure and skills I need to effectively communicate and gather the information I need, but I also hope to preserve some of the emotions I felt today.  They anchor me in humanity.

I arrived home under a sky that looked like the ocean.  Swaths of coral clouds banked against the pale blue expanse, sea foam on the waves.  The air was beginning to take on the lightest chill.

After dinner, I sat down and lifted my stethoscope from its box.  Outwardly, the moment didn’t appear ceremonious, but it meant a lot to me.  I placed the diaphragm of the stethoscope against my shirt, just to the left of my sternum.  According to my anatomy lecture this week, this location—the left sternal edge of the second costal cartilage—was the best place to hear my pulmonary valve.  This is where deoxygenated blood rushes to my lungs, extracting life from every breath.

I heard nothing.

Since I knew I was still alive, I decided that it was a technical issue on my part and flipped the chestpiece over to its other side.  Instantly, the rhythmic thud flooded my ears with all the intensity and wonder of hearing the ocean within a shell.

I was startled by how amazing it felt to hear my heartbeat.  In anatomy dissections this week, I peered into the chambers of the heart, felt around the valves, and compared the thickness of the muscle in the left and right ventricles.  As fascinating as this was, hearing the living pulse of my heart was like glimpsing a vibrant painting after seeing the preliminary sketches. 

I rotated the chestpiece so that I could use the diaphragm to listen and began methodically working my way through the four positions on my chest, hearing a discordant roar in my ears as the diaphragm brushed the folds of my shirt.  Every sound was enormously amplified, and I could hear my fingers on the chestpiece rim as I located the four landmark points we learned in anatomy.

Second costal cartilage, along the left sternal border…the pulmonary valve.

Second costal cartilage, along the right sternal border…the aortic valve.

Xiphisternum…the tricuspid valve.

Fifth intercostal space, along the midclavicular line…the mitral valve.

I cannot yet identify the different types of sounds I heard this evening, other than the lub-dub that marks the rhythm of systole and diastole, but I know that with time I will learn.  Just like how I will learn the steps to gathering my patient’s history, and how I will learn to communicate gracefully and with confidence.

But in this moment, I know I can listen.